Dr Kiri Oates is an emergency medicine registrar who trained in the UK and is experienced in adult and paediatric emergency medicine and intensive care. She qualified from Dundee University and completed the UK foundation training program in Portsmouth. She moved to Bristol to complete her core emergency medicine training and achieved membership to the Royal College of Emergency Medicine. Since qualification she has developed an interest in event and expedition medicine, allowing her to combine her personal passion for travelling with her training. This has included volunteering as medical support for Festival Medical Services, Exile Medics and Extreme Medics over the years. These companies and charities provided exciting training experiences such as working with ultra-marathon runners in the Amazon and Nepalese mountains, supporting down-hill cycling championships in Scotland and Wales and providing medical support at Glastonbury Festival. She also has a special interest in medical education and is currently working with the University of Sydney to train rural medical students based in Dubbo in emergency and retrieval skills. Now based in New South Wales, Australia, she is working as an emergency medicine and retrieval registrar in mainly adult retrievals in NSW with the Royal Flying Doctor Service.
Kate Osborne is the Statewide Telerehabilitation Program Manager for SA Health and, in partnership with multiple local health networks, has been leading the expansion of telerehabilitation across SA to improve consumer access to rehabilitation services. With a regional allied health background Kate is passionate about leading and influencing complex system change that supports staff to empower consumers to focus on improving their health and wellbeing.
Aims: Evidence supporting effectiveness of rehabilitation provided using telehealth (telerehabilitation) is growing nationally and internationally. Following a successful pilot project within the organisation, a decision was made to expand telerehabilitation services across the state.
Methods: Consumers across the state are able to loan iPads, or use their own technology, to enhance their rehabilitation program in the home environment. Consumers are able to connect with the entire rehabilitation team for consultations, assessments and therapy as well as utilising the technology to engage with extra goal-oriented activities.
The organisation invested significantly in local support positions for each Local Health Network, as well as central leadership positions and new ‘off-the shelf’ equipment, acknowledging that telehealth establishment requires timely ‘at the elbow’ support for problem solving technical challenges and supporting clinicians and consumers with understanding and accessing the technology.
Relevance: Enablers and barriers experienced during this statewide implementation process are consistent with anticipated factors and evidence published. Key factors that have supported growth include identification of clinical champions, consistent provision of data to staff and managers, a combined top down and bottom up approach, a training approach that supports individuals and functional teams as well as statewide communities of practice, a balance between statewide consistency and local flexibility, and the adoption of user friendly technology.
Key barriers that may inhibit future growth include the impact on service delivery of the current IHPA pricing model, the perception that telehealth is a lesser substitute, the lifespan and costliness of the equipment, inadequate bandwidth and mobile coverage (particularly in remote areas) and the culture and mindset shifts required to accept telehealth as quality, safe and effective practice. In order to build long-term sustainability, consideration must also be given to future workforce design and minimising complexities involved in managing a secure, encrypted, reliable technology system.
Results: Telerehabilitation activity has doubled across the state in the 2017/18 financial year with consumer feedback remaining positive. 80% of consumers who participated in surveys agree or strongly agree that they received the same standard of care as they would have from a face-to-face appointment, and 88% agree or strongly agree that they would participate in another telerehabilitation consultation in the future.
Conclusion: Sustainable service reform requires continued leadership, organisational investment and ensuring effective consumer and clinician engagement. The organisation is committed to training and support models plus an ongoing quality improvement approach that engages consumers, staff, teams and the organisation.
Laura O’Connor is currently working as an ENT registrar at Royal Darwin Hospital. She studied undergraduate medicine at the University of Tasmania. Since graduation she has work in rural Queensland, NSW and tertiary centres in Sydney. As part of her current role, she has the opportunity to participate in outreach programs to small isolated communities, designed to close the gap in Indigenous hearing.
People living in rural areas have poorer health outcomes compared to their urban counterparts and the ability to provide equivalent health services is an ongoing problem in Australia. Telehealth offers us the ability to provide improved health services to these areas. The isolated area of the Top End of Australia is at particular disadvantage when accessing health resources. It has a small population of 196 000, of which 30% are Indigenous and 80% live in remote communities.
The ENT Department, at Royal Darwin Hospital, as part of its Indigenous Outreach services, implemented a teleotolgy program to assist in meeting the demand for remote services. It aims to provide continuity of service with the same small group of clinicians, in order to build patient rapport and trust so we can work better together to reduce the burden of ear disease and raise awareness of same through health promotion.
Indigenous children in the Northern Territory have the highest recorded rates of ear disease in the world. The WHO declares a 4% rate of CSOM a public health emergency—in 2017 Indigenous children in the Top End had a rate of 12%. Only 1 in 10 have normal bilateral hearing, by 60 days of age, 60% of babies are colonised by all three OM bacterial pathogens and 80% have middle ear effusions. 77% of 0-5 year olds have OME and 40% have perforations by 18 months of age. At least 20% of children are suffering significant hearing loss by school age, affecting communication, learning and behaviour and this rate is much higher in some communities. 90% of Indigenous prisoners have some level of hearing impairment.
Not only is providing these children with a hearing service problematic, having them engaged in on going care is also difficult. Without outreach services, only 60% received post-operative review. Logistic limitations due to inclement weather and road closures, nomadic lifestyle, adult guardians not being available to attend with the child community events such as ceremonies and funerals are all challenges to care.
To overcome the difficulty in bringing patients to Darwin for otology review, teleotoly has allowed us to bring a mobile assessment clinic to the communities. The program is comprised of ENT clinical nurse consultants, child hearing health coordinators, Aboriginal health practitioners and audiologists. They travel to communities and carry out digital otoscopy (photos are taken of the tympanic membrane), clinical assessment and an audiogram. This electronic data, is forwarded to an ENT specialist for review and management advice. With this initiative, we are able to overcome problems with lack of attendance at Darwin Hospital and review a significantly higher number of Indigenous children for ear health. We also aim to improve community involvement and awareness by engaging with people in their own communities.